<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881034
Report Date: 10/16/2023
Date Signed: 10/16/2023 02:44:39 PM


Document Has Been Signed on 10/16/2023 02:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:BROOKDALE LOMA LINDAFACILITY NUMBER:
361881034
ADMINISTRATOR:LUJAN, MARITZAFACILITY TYPE:
740
ADDRESS:25585 VAN LEUVEN STREETTELEPHONE:
(909) 796-5421
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:220CENSUS: 108DATE:
10/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Maritza Lujuan, Executive Director TIME COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/16/2023, at 02:17 p.m., Licensing Program Analyst (LPA) Rayshaun Nickolas arrived at the facility unannounced to obtain signatures on amended reports. LPA Nickolas met with Executive Director Maritza Lujan and explained the purpose of the visit.

An exit interview was conducted, where a copies of this provide and amended LIC 9099s were provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1